Report of events held with members of the public

Key issues from the events

1. During February 2010 the NMC held a series of open invitation events around the UK for members of the public to find out more about the work of the NMC and to raise any questions or issues. We also held a whole-day session with the National Voices User Panel in October 2009.
2. This report summarises the key issues that emerged from the sessions and highlights recommendations for the NMC given these findings. It also includes feedback gathered at a meeting of the Greater London Older People’s Forum BME group in January 2010 and of the Public Partnership Forums Chairs event held by Scottish Health Council in March 2010.
3. The NMC would again like to thank all those who took the time to come and meet with us and the organisations that supported this, in particular the Patient Client Councils in Strabane and Belfast, the Northern Ireland Council for Voluntary Action (NICVA), the Scottish Dementia Working Group and National Voices.

Questions and clarifications for the NMC

1. All of the sessions included an information session on the work of the NMC and a chance to ask questions about our work and role. Questions asked highlight areas of interest as well as confusion. Key questions were:
   1. Who we regulate: Does it include healthcare support workers (HCSWs) and auxiliaries? Is it just the NHS? Do we regulate people who trained abroad?
   2. Who we are: How long has the NMC existed? How is the NMC funded? What is the background of the lay Council members? What is the ethnic profile of council members? How do we work across the four countries – do we have offices in each?
   3. Who we are not: Are we the same as the Royal College of Nursing? Are we a Union – do we represent nurses? Are we part of the NHS?
   4. Who we work with: Who regulates the NMC? How do we link with government and other regulators?  Why are there different regulators for different professions? Do we work together?
   5. How we work with the public: Should people make complaints directly to the NMC? Should the public have a copy of the code?
   6. How we work with nurses and midwives: How do we support nurses and midwives who have allegations against them? How do we make sure nurses and midwives aren’t blamed for others’ mistakes? Which rules do nurses and midwives follow – the NMC’s or the employers’? How do we know that nurses and midwives are still safe to practise?
   7. The code: Is the code part of education programmes? How is the code used in practice? How often is the code reviewed? Are people tested on the code later in their careers?

The NMC’s communications and public face

1. Participants in the sessions largely gave very positive feedback and were interested in finding out more about the NMC. Most felt that patients and users should know more about its role and, in particular, about the code – many commented that they felt that the public should be more aware of the standards they should expect. They had a number of ideas for how the we could get our messages across appropriately:
   1. Work in partnership with other organisations, particularly local patient groups, and create links.
   2. Attend more events, conferences and seminars to increase people’s awareness of the NMC and our role.
   3. Inclusion in information packs distributed to carers and to people living with chronic conditions.
2. Participants were shown a variety of our publications and made a number of comments:
   1. Positive comments were made regarding our plain English style of communication, transparency about our role and what is included in our remit of work.
   2. The code was regarded as a useful and beneficial document that should be publicised more to the public and carers. A lot of people were not aware of its existence, but presumed there would be some sort of legislation for nurses and midwives.
   3. The large print copy of the code was very accessible. For example, no underlining or italics made it easy to read.
3. There were also suggestions for how our communications could be improved in future:
   1. There should be information in every care setting about professional regulation to instil confidence in the public.
   2. Ensure that documents also have a “public facing” version that is aimed at users of services.

Issues and concerns about nursing and midwifery care

1. A variety of concerns and issues were raised by people attending the sessions. These included concerns about staffing levels, particularly with fears of potential future service cuts, and about perceived falls in overall standards of care. Issues of agencies failing to work together locally, about the standards of care and support offered in the community, and about poor quality information came up in multiple sessions. Participants also had a number of moving stories regarding good and poor quality care they and their loved ones had received. Where appropriate they were advised on how to pursue concerns locally.
2. A number of issues that are directly or indirectly related to the work of the NMC were also raised in multiple sessions. 

Health care support workers (HCSWs)

1. There was confusion about the unregulated status of HCSWs, with some attendees expressing surprise that they were currently unregulated or concern that they were either difficult to distinguish from nurses or doing similar jobs to them.
2. Some respondents felt this to be particularly pertinent as there were concerns that support workers fulfil, and will continue to, roles that were previously occupied by registered nurses or midwives.
3. A variety of solutions were offered, including forced display of registration status, the return of enrolled nurses, differing uniforms, better supervision/more nurses, and regulation by the NMC or General Social Care Council.

Nurse training and education

1. A number of participants expressed fears about current nursing education, with many fearing that it was not practical enough and that people were more concerned with academic achievement than the softer skills of caring and empathy. This seemed linked to concerns that nursing itself was seen as a stepping stone to management, and that it was not attracting the “right sort” of people. In England there were concerns that degree based education would exasperate this, whereas in countries with a higher proportion of existing degree based courses these concerns were generally not shared.
2. There was widespread support for the measures outlined in our explanation of the review of pre-registration nursing education, particularly in the continued emphasis on caring and essential skills, the emphasis on dementia care and on holistic care, and on working with families and carers. The need to include training on how to identify abuse was also raised. Some participants were concerned that all of the equality and diversity streams were not taken into account during the consultation.
3. There were concerns that geriatric nursing is not a nursing specialisation even though the UK has an ageing population. Many felt that the same standards of care should be given to any adult regardless of their age. The issue of supporting people with physical disabilities was also raised.
4. The contribution made by foreign-born nurses and midwives was highlighted. However some attendees were concerned that those who trained outside the UK need to achieve not just language competence, but also cultural competence.
5. The importance of positive role models for those new to the professions, and portraying positive images in the media, was also emphasised.

Standards of care and supervision 

• The caring skills required by nurses and midwives - empathy, respect and positive attitude – were highlighted, along with examples of where this had and had not occurred. Dignity was a recurring issue, with some participants asking how the NMC monitored levels of care in this area.
• As with nursing education, there was some distrust of modern healthcare delivery methods, with computers and technology being seen as more visible than essential care. 
• A large number of participants were fearful for the future of care as budget cuts lead to a decrease in the numbers of nurses and midwives. There were concerns that this could impact upon the ability of nurses and midwives to follow their code.
• Midwifery supervision and Intention to Practise (ITP) was regarded as a beneficial method of monitoring midwives – some called for a similar system to monitor nurses.

Raising concerns and the healthcare environment  

• A number of participants were concerned that nurses and midwives were scared to speak out about the quality of care, either because the environment was not supportive to do so, or because they feared repercussions from their colleagues, employer or the NMC.
• The NMC was seen as needing to be supportive of nurses and midwives in these situations, while still making clear their responsibilities. The need to ensure that nurses were not blamed for the mistakes of others, such as doctors, or the failings of the healthcare environment was highlighted.
• There were a variety of concerns regarding members of the public raising concerns, particularly:
  • Patients feared raising concerns because they feared the repercussions, particularly if they receive long term care.
  • This was particularly the case for vulnerable groups, such as older people.
  • People do not know where to go to raise a concern and local support organisations, such as the Independent Complaints and Advice Service, are not well known.
  • There are a confusingly large number of organisations where a complaint or concern could be raised and they need to work better together to provide clear information.

The regulation field

1. There were concerns that the large number of different regulators is confusing and it was difficult to know what to expect from healthcare professionals. There were calls for regulators to work together on issues such as revalidation, and in providing information.

The code

• Participants were supportive of the content of the code, but made some suggestions:
  • The word “enable” should be used in the code as this gives the impression that nurses and midwives help people to look after themselves, promote healthy living and have a personal responsibility.
  • Rather than saying “you must…” the code should perhaps in some areas say that “it is your duty…”  Also, rather then saying that “you should” it should say that “you and your colleague should…” this incorporates how nurses and midwives should work as a team.
  • There should be more emphasis on working with families and carers.

Comments about the events

• Participants were given the opportunity to comment on the events. The following is a sample of the comments made:
  • “Did not know about the code. Would like to be involved in any further consultations especially regarding BME issues. Interesting informal discussion made it easier to comment on any issues. Presentation made clear at the start re NMC”.
    “Very good interaction and acknowledgement of service user views”.
    “Greater care needs to be given to getting people to respond to the things that you want to know. More time for general discussion needed”.
    “What is the NMC doing to support nurses in providing safe, caring knowledgeable nurses? It is not sufficient to say ‘nurses must’ in the code without being made proactive in supporting nurses”.
    “I wasn’t sure who was running the event …and was a ‘bit’ perturbed when I arrived. However, I found the session very helpful and it did indeed have relevance to the work I am involved in”.
    “There was too wide a range of needs had to be met”.
    “This was a very informative session reaching out to the local community to raise awareness of the roles of the NMC and on how to improve nursing and midwifery”.

Next steps

1. We will consider how best we can use the learning from these and any future events to influence our work and how we work with the public in the future.
2. A version of this report will be presented to the Executive Management Board at the NMC.
3. Amongst other things it will be recommended that we use the comments and key questions asked, to inform the development the pages for the general public on our new website and any new communications; we continue to consider accessibility in new publications; we include comments on the content of the code when it is next reviewed; and we continue to support the Council for Healthcare Regulatory Excellence’s (CHRE) work on promoting the role of professional regulation, such as through leaflets.